NURS 6512 Building a Health History
NURS 6512 Building a Health History
NURS 6512 Building a Health History
Building rapport with the patient
As advanced practice registered nurses (APRNs), it is imperative to obtain a thorough health history from the patient interview process. The history is vital to guiding the physical examination and to interpreting physical exam findings ( Ball et al., 2019). One way to effectively build a health history during the interview process is to develop a rapport or relationship with the patient. Establishing a positive patient relationship depends on effective communication built on courtesy, comfort, connection, and confirmation (Ball et al., 2019).
Each patient is unique and must be treated as such. Communication and interview techniques for building a health history can differ with each patient based on age, learning abilities, and the patients’ reading level. The purpose of this discussion is to identify techniques in building a health history with an adolescent white male with no insurance seeking medical care for an STI.
Crucial factors of consideration
According to the World Health Organization (WHO), adolescence is the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique stage of human development and an important time for laying the foundations of good health (2022). Even through the adolescent years, there are significant diseases/illnesses and injuries. During this phase, adolescents establish patterns of behaviour – for instance, related to diet, physical activity, substance use, and sexual activity – that can protect their health and the health of others around them, or put their health at risk now and in the future (WHO, 2022). During the adolescent phase, it is important to provide correct age-appropriate sexual activity information.
Assessment
The collection and analysis of information regarding an individual’s current and overall health is a health assessment and is provided by the patient subjectively (Ball et al., 2019). Considering this patient is coming to the appointment for concerns for an STI, it is imperative for the APRN to not be judgemental. This will allow the patient to feel comfortable sharing information such as signs and symptoms of the probable STI, number of partners, past history of an STI, and their gender identity.
The physical assessment is just as important as obtaining a health history. Physical exams should include inspection, auscultation, percussion, and palpation of the patient to verify the patient’s report objectively (Ball et al., 2019). As part of the physical assessment, the APRN may also conduct a male genitalia examination and obtain cultures of fluid to test for certain STIs such as, chlamydia, gonorrhea, and syphilis. Labs may also be ordered to check for those certain STIs.
At the end of the examination, targeted needs would be beneficial to address. For example, this patient does not have medical insurance. Since the patient is an adolescent, one would assume they are on their parent’s medical insurance as a dependent. Sometimes, adolescents are too afraid and uncomfortable to tell their parents and/or guardians any reproductive issues. Oftentimes, adolescents come into clinics secretly and say they do not have medical insurance so their parents/guardians do not find out about the visit once billed.
Asking questions such as why don’t you have insurance? Do your parents/guardians have medical insurance? Do they know about your visit to the clinic today? Can help identify any patterns or concerns without being assumptive. Providing support and comfort can help alleviate any hesitancy in answering the above questions. Finding and establishing important resources can help make sure the patient is getting the care they need outside of the clinic.
Specific targeted questions
Asking appropriate questions and avoiding stereotypes is essential to providing care that is tailored to the individual patient (Ball et al., 2015). With this particular patient, sexual information should be obtained in a non-judgemental manner. Targeted questions such as 1) What brings you to the clinic today? 2) How many partners do you currently have? 3) What are your current sexual practices (anal, oral, vaginal)? 4) What protection do you use to prevent STIs? 5) Have you had any STIs in the past? 6) What are your symptoms? And when did they start? Utilizing the screening tool PACES would also be beneficial for this patient. PACES stands for parents/peers, accidents/alcohol/drugs, cigarettes, emotional issues, and sexuality/school (Ball et al., 2019). PACES identifies these categories specifically for adolescents because oftentimes they are what is important to this age group.
Conclusion
A successful health assessment and interview process between an APRN and their patients requires a good rapport/relationship as the foundation. Identifying considerations and tailoring specific targeted questions to individual patients can be beneficial. Patient-centered care is an important contributor to a positive patient care experience (Dang et al., 2017). Actively engaging and listening to each patient is important. This will help the patient feel more comfortable expressing their concerns and needs.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Dang, B. N., Westbrook, R. A., Njue, S. M., & Giordano, T. P. (2017). Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC medical education, 17(1), 1-10.
World Health Organization. (2022). Adolescent health. Retrieved from https://www.who.int/health-
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The patient in this scenario is a 14-year-old biracial male. The first step in interacting with the patient is to build a trustworthy rapport with the patient and determine his fluency in communication and speaking the English language, as any language barriers can hinder the effectiveness of the communication, it is important to ensure the client understands the language of communication (Brooks et al., 2019). Effective communication is required needed in any patient-healthcare provider interaction. The language assessment is important in making communication easier.
Communication Techniques
Furthermore, the use of verbal techniques will be ensured in the communication process (Wang et al., 2018). However, caution will be taken not to offend the client in the conversation. The meaning and interpretation of the non-verbal techniques tend to vary from one cultural group to another (Sullivan, 2019). Therefore, considering that the client is from another cultural group and young, understanding their values would be necessary to reduce the conflicts in the communication process. I will also be empathetic to the client (Ball et al., 2019).
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Subsequently, active listening is also important when interacting with the patient. Listening actively help the healthcare provider to capture important information about the patients and their possible health needs (LeBlond et al., 2014). On the other hand, some clients may be too talkative and so the healthcare provider must be able to control and ensure that the relevant information is obtained from the interaction. Controlling the conversation also helps in managing the time used in the interaction. The HEEADSSS risk assessment tool will be used when interviewing the patient because it will help in understanding the client’s home environment and education experiences among other areas of interest.
Target Interview Questions
1. Whom do you live with at home?
2. What is your relationship with the parents and siblings?
3. What is it that makes you happy about your family?
4. Who is your best friend?
5. What do you like doing during your free time?
Conclusion
Finally, communication is important in the interaction between the patient and the healthcare providers. Both verbal and non-verbal communication matters in the interaction. Cultural values vary from one patient to another and this could be a major hindrance to effective interaction between the patient and the healthcare providers. Therefore, the nurses must demonstrate cross-cultural competencies and interact with their clients accordingly without judging them or looking down upon their cultural values.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Brooks, L. A., Manias, E., & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Wang, Y., Wan, Q., Lin, F., Zhou, W., & Shang, S. (2018). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International Journal of Nursing Sciences, 5(1), 81-88. https://doi.org/10.1016/j.ijnss.2017.09.007
As an advanced practitioner, it is imperative to build a therapeutic relationship with the patient to obtain the most and accurate health history of that specific patient; the medical history is a crucial information in developing an appropriate plan of care for that patient. Each patient may require different communication techniques and considerations based on their social determinants of health and health risks. In this week’s discussion, I am presented with an adolescent white male that is without health insurance and seeking medical care for a sexually transmitted infection. The purpose of this discussion is to examine communication techniques specific to my patient and at least five targeted questions to assess the health risks and building of patient’s health history.
Health History Interview
Since the patient is an adolescent male that presents with STI, my priorities would be identifying high risk behaviors such as use of illicit drugs and alcohol, risky sexual behaviors, and suicidal ideations. According to Johnston et al. (2022), data from 184 countries in nine UNICEF regions suggested that there are approximately 17 million adolescent young men who are bisexual and sell sex that needs HIV prevention services and social support. In addition, America Foundation for Suicide Prevention (2022) stated that 8.9% of youth grades 9-12 reported having at least one suicide attempt within 12 months. Therefore, my targeted questions would include:
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- Do you smoke or drink? If so, how many times a week?
- What is your sexual orientation? (ex. heterosexual, bisexual, etc.)
- Do you use any illicit recreational drugs?
- How many sexual partners have you had in the last month?
- Have you ever had suicidal ideations or attempts?
Communication Techniques
There are many barriers in obtaining accurate and sufficient health history; in my patient’s case, he is an adolescent teen who may be hesitant to tell the honest answer when it comes to sensitive subjects such as alcohol, recreational drug use, or sexual orientation. Many adolescents are exploring to find self-identity during this time and unfortunately, it often involves high-risk behaviors. Mental health has been more recognized in the last decade, and suicidal ideation awareness and assessment has been more widely adopted in healthcare settings. Ball et al. (2019) stated that when discussing sensitive issues, there are many essential considerations during the interview such as providing privacy, being direct and firm by avoiding leading questions, not apologizing for asking a question, not being judgmental or pushy, and using language that is understandable but not patronizing. First impression is a big factor when introducing yourself to the patient; for this patient, I would try to initially relate to the patient by talking about common hobbies that can relate to adolescents such as games or sports and build a trusting relationship. I would be firm in saying that you need to tell me the truth about alcohol or drug use, but that the information would stay confidential, and I will not purposely expose information that would get the patient in trouble with his guardians or with the law.
One assessment tool that can be used for my patient that would help with obtaining health history is the ‘CRAFFT’ questionnaire. It was developed in 2002 as a screening tool for alcohol and substance abuse in adolescents; a two or more (2 to 6) yes answers suggests a serious substance use disorder problem and the questionnaire also recommends counseling regarding many aspects such as reviewing the screening results, recommending not to use such drugs, driving risk counseling, eliciting self-motivational statements, and reinforcing self-efficacy (New Jersey Chapter: American Academy of Pediatrics, 2018). This assessment tool is important because the patient’s social background and high-risk behaviors may be correlated with patient’s sexual behaviors that led to patient having an STI.
Conclusion
Obtaining patient’s health history takes more than just interviewing the patient; it takes a lot of effort in building a trusting relationship and understanding their personal situation and poor social determinants of health such as poverty or no insurance that is constant even after they are discharged from the healthcare setting. Assessing each patient with individualized plan of care and applying the correct communication techniques that apply to different age groups/gender/ethnicity are key in building a therapeutic relationship with the patient that will yield in better health outcome.
References
American Foundation for Suicide Prevention. (2022). Suicide statistics. Retrieved November 29, 2022 from https://afsp.org/suicide-
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Johnston, L., Nguyen, V., Lwamba, C., Sabin, K. (2022). Deriving and interpreting population size estimates for adolescent and young key populations at higher risk of HIV transmission: Men who have sex with men and females who sell sex. PLoS One, 17(9). https://doi.org/10.1371/
New Jersey Chapter: American Academy of Pediatrics. (2018). The CRAFFT Questionnaire (version 2.1). https://njaap.org/wp-content/
Sarkisian, K., Planalp, E., Carol, V. H., & Goldsmith, H. H. (2022). Leveraging latent profile analysis to synthesize childhood and adolescent risk factors for suicidal ideation. PLoS One, 17(8). https://doi.org/10.1371/
Discussion: Building a Health History
Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:
• Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
• Suggest additional health-related risks that might be considered.
• Validate an idea with your own experience and additional research.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion
What’s Coming Up in Module 2?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.
Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity
Registration for Shadow Health
Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.
There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:
• Health History Assessment (Week 3 & 4)
• Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
• Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
• Comprehensive (Head-to-Toe) Physical Assessment (Week 9)
Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:
• Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
• Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
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• Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
• Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
• Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be